Landmark School-Based 'Social Influences' Smoking-Prevention Program Found Not to Work

Results of 15-year study in tomorrow's Journal of the National Cancer Institute

SEATTLE - The most ambitious, school-based smoking-prevention study of its kind has found that teaching youth how to identify and resist social influences to smoke - the main focus of smoking-prevention education and research for more than two decades - simply doesn't work.
These findings, to appear tomorrow in the Journal of the National Cancer Institute, are based on a 15-year, federally funded smoking-prevention study conducted by the Fred Hutchinson Cancer Research Center in Seattle. The study, which involved nearly 8,400 students and more than 600 teachers throughout 40 school districts in Washington state, was the largest and longest study ever conducted in school-based smoking-prevention research.
The goal of the study, called the Hutchinson Smoking Prevention Project, or HSPP, was to find out whether a school-based smoking-prevention program using a social-influences approach can keep youth from smoking throughout and beyond high school. The social-influences approach centers on countering the social influences to smoke, from peer pressure to tobacco advertising.
The National Cancer Institute funded the $15 million study as part of a national research effort to address the increasing prevalence of daily smoking in youth. If the current trend is not reversed, an estimated 5 million of today's youth will die prematurely from smoking-related illnesses, according to the Centers for Disease Control and Prevention.
The study began in 1984, and follow-up surveys were completed in 1999. Half of the study's 40 rural and suburban school districts were randomly assigned to the experimental group, which implemented the smoking-prevention program, and half served as comparison, or control, districts, teaching their usual health programs.
Because smoking almost always begins during or prior to the teen years, the HSPP intervention covered virtually the entire age range of smoking onset, starting early (third grade), and continuing into high school (10th grade).
Despite rigorous study design, faithful teaching of the program, and a high rate of follow-up of the study participants, the HSPP saw no difference in smoking behavior between the experimental and control groups.
Questionnaires completed by the students during their senior year, and again two years after high school, showed almost identical rates of smoking between the two groups. For example, among 12th grade girls, 24.4 percent in the experimental group smoked daily, little different from 24.7 percent in the control group. For 12th grade boys, the percentages for daily smoking were 26.3 percent experimental and 26.7 percent control.
The project's lead investigator, Arthur V. Peterson Jr., Ph.D., says that these results clearly show the current approach to smoking prevention via school programs isn't enough to deter youth from smoking.
"Surprisingly and disappointingly, we found a striking similarity in smoking prevalence between the experimental and control groups," says Peterson, a member of the Hutchinson Center's Public Health Sciences Division and a professor of biostatistics at the University of Washington School of Public Health and Community Medicine.
The trial's results, while unfortunate, are definitive, Peterson says.
"Tobacco-prevention researchers and educators have been pinning their hopes on the social-influences theory of smoking prevention for the past 25 years without knowing for sure if it works. Because of the high degree of rigor achieved in this trial, the failure to observe reduced smoking prevalence in the experimental group can be attributed only to the failure of the intervention," he says.
NCI Director Richard Klausner, M.D., acknowledges the importance of this study. "Although the study demonstrated that this approach had no effect, it provides a valuable contribution to our knowledge about smoking behavior," he says. "Carefully conducted studies such as this one help us to understand what works and what does not in the area of youth smoking."
The smoking-prevention program was designed not only to help youth identify and resist influences to smoke, but also to correct their inaccurate perceptions about smoking and motivate them to want to be smoke-free. The program was delivered by regular classroom teachers who had been specifically trained for the task by Hutchinson Center staff.
Lessons engaged students in a wide variety of activities. Examples of just a few include: third graders making paper-bag puppets and performing a puppet play about the dangers of second-hand smoke and the value of breathing clean air; seventh and eighth graders using role-play and coaching exercises to practice new skills for countering offers of tobacco; and ninth graders re-enacting testimony from several landmark tobacco-liability trials to discover the tobacco industry's attempts to conceal the deadly consequences of smoking.
"The teachers did their darndest, and the educational materials were top-notch," Peterson says. "The inability of the program to affect change in smoking behavior comes down, in our judgment, to one thing: the failure of the social-influences strategy of the last 25 years. It simply didn't work."
Credence in the results is enhanced by the high degree of scientific rigor achieved by the study, as evidenced by the following:

The study was large, involving 40 geographically and demographically diverse school districts and more than 8,400 children.

Each district participated fully in all research activities throughout the duration of the study; none dropped out.

The study was randomized by school district, not by individual school - a unique feature that eliminated the threat of so-called "contamination" by social mixing between students in the experimental and control groups.

Teachers who taught the program were well trained; 100 percent of the assigned teachers received in-service training, and more than 99 percent of these teachers taught the curriculum to their students. Classroom observations by Hutchinson Center staff also showed good implementation results; teachers effectively communicated the program's key concepts in 80 percent of lessons observed.

The vast majority - 94 percent - of the original third-grade study participants completed surveys at two years after high school.

In addition, the program included the "essential elements" for school-based tobacco prevention recommended by a national Expert Advisory Panel convened by the NCI. It also met the guidelines for planning and implementing effective school-based programs for the prevention of tobacco use recommended by the CDC.
"This study was carefully conceived and meticulously performed, and it achieved a new standard of scientific rigor for prevention research," says Richard Clayton, Ph.D., The Good Samaritan Foundation Professor of Health Behavior and director of the Center for Prevention Research at the University of Kentucky School of Public Health.
"The program was demonstrated to have been faithfully implemented by the teachers. The study's achievement to follow up 94 percent of the study participants to two years post high school is truly remarkable. This new standard of rigor will be invaluable in providing a blueprint for future prevention research," Clayton says.
Peterson and colleagues conclude that it may be time to take a totally new approach to smoking prevention that incorporates different theories, different intervention strategies, different venues and/or different providers.
"The fact that the intervention didn't have an effect means that it is time for researchers to go back to the drawing board to re-examine the smoking-onset process in children and develop new strategies for reaching youth," Peterson says.
"We expect that the results of the study will be a sharp stimulus to researchers to redouble their efforts to find the key to effective smoking prevention among youth. Certainly, this study has shown that rigorous school-based research is possible and practical for testing new approaches in the future," he says.
Peterson praises the interest and cooperation of the 40 Washington school districts that participated in this landmark trial. "This was truly a team effort involving many thousands of people across the state. This study experienced great cooperation from students, parents, teachers, administrators and staff. We are so grateful to them. Without this support we could never have maintained the rigor of this study and found the answer to this vitally important research question."
Project collaborators from the Hutchinson Center's Public Health Sciences Division were Kathleen Kealey, C.T.R., intervention manager; Sue L. Mann, M.P.H., data operations manager; Patrick M. Marek, M.S., database manager; health psychologist Deborah J. Bowen, Ph.D., a member of the PHS division and an affiliate assistant professor of psychology at UW; and economic analyst Nicole D. Urban, Sc.D., a member of the PHS division and an associate professor of health services at UW. Also collaborating on the study was UW psychology professor Irwin G. Sarason, Ph.D.
This NCI-funded trial was supported in part by a generous donation from the Northern Life Insurance Company.